Basic Information
| Provider Information | |||||||||
| NPI: | 1992977904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY KRIEGER EDUCATION AND COMMUNITY SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KENNEDY KRIEGER SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 744865 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231895 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 SOLOMONS ISLAND RD. | ||||||||
| Address2: | ANNE ARUNDEL II SOUTHERN SCHOOL | ||||||||
| City: | HARWOOD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102354801 | ||||||||
| FaxNumber: | 4439239405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4439231810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | MH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 163WC0400X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management | 225100000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QD1600X | 30-036 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 1754815 07 | 05 | MD | MEDICAID |